In a closed chest injury, the chest is injured but there is no break in the skin.

A closed chest injury can be caused by a blow to the chest by a blunt instrument, a fall, a cave-in, or a vehicle accident. The following are signs and symptoms of a closed chest injury.

a. Pain in the chest area.  The pain may be due to injury to the rib cage and muscles (pain indicates the site of the injury) or to pleurisy (inflammation within the chest cavity). The pain usually increases when the casualty breathes.

b. Labored breathing or difficulty in breathing (dyspnea).

c. Diminished breathing sounds or absence of such sounds.

d. Rapid and weak pulse with low blood pressure.

e. Cyanosis (bluish tint) usually seen first in the lips, nail beds, or inside the mouth.

f. Failure of one or both sides of the chest to expand normally when the casualty inhales.

g. Paradoxical breathing. Paradoxical breathing, an indication of a flail chest, occurs when part of the chest moves in when the casualty inhales and out when the casualty exhales–the opposite of normal motion.

h. Coughing up blood (hemoptysis) or bloody sputum.

i. Enlarged neck veins.

j. Bulging tissue between the ribs or above the clavicles (collarbones). This sign is an indication of tension pneumothorax or hemothorax.

k. Tracheal deviation (a shift of the trachea from its normal midline toward the unaffected side of the casualty’s body). The shift is caused by the buildup of pressure on the injured side due to tension pneumothorax. Tracheal deviation is a very late sign.

l. Mediastinal shift (movement of the mediastinum–heart, great blood vessels, trachea, and esophagus–from its normal position toward the unaffected side of the body). Mediastinal shift is caused by the buildup of pressure due to tension pneumothorax or hemothorax.

CAUTION: Mediastinal shift indicates a life-threatening condition (compression of the heart and blood vessels). The pressure must be relieved as soon as possible by trained medical personnel.